In most men, serum testosterone concentrations decline steadily with age. Studies report that the total serum testosterone concentration of men at age 75 years is about two-thirds of the levels at age 25 years. Approximately 50% of men older than 80 years and about 20% of men older than 60 years have low serum testosterone concentrations. However, some men may go through a rather sudden change in testosterone levels. Signs and symptoms may include:

  1. weakness
  2. fatigue
  3. osteoporosis
  4. heart disease
  5. atherosclerosis
  6. irritability
  7. depression, anxiety
  8. metabolic syndrome
  9. slow wound healing
  10. reduced libido
  11. erectile dysfunction
  12. prostate problems
  13. low sperm counts
  14. reduced muscle mass
  15. disturbed sleep; insomnia
  16. impaired blood cell formation
  17. reduced cognitive function

The diagnosis of low testosterone levels (hypogonadism) is based on the presence of signs or symptoms and must be confirmed by laboratory testing, which should include Total Testosterone, Bioavailable Testosterone (Free plus Albumin Bound), Estradiol, Cholesterol, Prostate Specific Antigen (PSA), Complete Blood Count (CBC), Hemoglobin, and Hematocrit. A consensus statement by the International Society of Andrology, International Society for the Study of Aging Male, European Association of Urology, European Academy of Andrology, and American Society of Andrology, concluded that men with a serum concentration above 350 ng/dL generally do not require therapy, while men with serum testosterone concentrations below 230 ng/dL will usually benefit from testosterone replacement therapy (TRT).

In older men, an optimal plasma testosterone level is associated with reduced all-cause mortality. When hormones are replaced or restored back to physiologic levels considered normal for younger males, men may experience a dramatic reversal of many signs and symptoms. Proper monitoring of laboratory values and clinical response are essential for optimal testosterone replacement therapy.

Testosterone Replacement Therapy for men with low testosterone levels may produce a wide range of benefits including:

  1. improvement in libido and sexual function
  2. increased muscle mass and body composition
  3. increased strength and stature
  4. preservation of bone mass
  5. improvement in mood and depression
  6. enhanced cognition, concentration and memory
  7. improvement in sleep and quality of life
  8. reduced risk of developing type 2 diabetes mellitus and metabolic syndrome
  9. possible decrease in cardiovascular risk
  10. lower cholesterol and triglycerides
  11. lower blood glucose levels
  12. decrease visceral fat mass
  13. normalize blood clotting


What is the Optimal Form of Testosterone for Replacement Therapy?

Testosterone USP is natural testosterone that has a monograph in the United States Pharmacopoeia (USP). Upon a prescription order, compounding pharmacists can use pure Testosterone USP to compound numerous dosage forms. The information that follows should be considered as doctor or health care practitioner, patient, and pharmacist work together to meet each patient’s specific needs. Compounded preparations can have many advantages. For example, there is no need to shave the area to apply transdermal testosterone preparations. The medication can be administered as a single dose (rather than multiple patches), and there is no skin irritation from patch adhesive. The cream or gel can be applied two or three times daily to simulate the normal circadian rhythm.

A healthy adult male secretes 8-15mg/day of testosterone. This “physiologic dose” should be considered when prescribing replacement therapy. Excessive doses leading to high serum levels of testosterone can result in a greater conversion to estradiol (and side-effects resulting from abnormally high estradiol levels), because the body cannot effectively store excess testosterone. This may be a reason to administer testosterone on a daily basis, rather than using long-lasting injections.

Transdermal drug administration allows application of a specific dose of a hormone to be applied to the skin and then be absorbed into the systemic circulation. Transdermal medications have the advantage of high bioavailability, absence of hepatic first pass metabolism, increased therapeutic efficacy, and steadiness of plasma concentrations of the drug. Testosterone is well-absorbed from transdermal creams/gels. Dosage forms also include sublingual drops or troches.
Natural testosterone must not be confused with synthetic derivatives or “anabolic steroids,” which when used by athletes and body builders have caused disastrous effects, such as heart problems and cancer. Use of synthetic androgens, like stanozolol or methyltestosterone, causes profound decreases in HDL-C and significant increases in LDL-C, and has been associated with serious heart disease. However, natural testosterone lowers total cholesterol and LDL cholesterol levels while having little to no impact on serum HDL cholesterol levels.

Screening for potential risks of androgen therapy should be performed prior to the initiation of treatment. Contraindications to testosterone replacement therapy include an elevated level of Prostate-Specific Antigen (PSA), or history or presence of prostate or breast cancer. There is a risk of worsening symptoms of benign prostatic hypertrophy (enlarged prostate), sleep apnea, congestive heart failure, gynecomastia (breast enlargement), infertility and skin diseases.

Drug Design, Development and Therapy 2014:8 101–112
Transdermal testosterone replacement therapy in men
Click here to access the PubMed abstract of this article.

Drugs Aging. 1999 Aug;15(2):131-42.
Risks versus benefits of testosterone therapy in elderly men.
Click here to access the PubMed abstract of this article.

Patients using testosterone should seek medical attention immediately if symptoms of a heart attack or stroke are present, such as:

  1. Chest pain
  2. Shortness of breath or trouble breathing
  3. Weakness in one part or one side of the body
  4. Slurred speech

Goals an Therapy

Goals of Testosterone Replacement Therapy in Adult Hypogonadal Men (age 50 or older)

  1. Improvement in psychological well-being and mood
  2. Improvement in erectile dysfunction
  3. Improvement in libido
  4. Increased muscle mass
  5. Increased strength and stature
  6. Preservation of bone mass

A man may be considered hypogonadal at any age if total testosterone is less than 200 ng/dl, or bioavailable testosterone is less than 60 ng/dl. Basaria and Dobs of Johns Hopkins University recommend that elderly men with symptoms of hypogonadism and a total testosterone level < 300 ng/dl should be started on hormone replacement.

Supporting Literature

Testosterone Therapy: Monitor Estradiol and DHT Levels

As men age, testosterone levels progressively fall and inflammatory biomarkers increase. The gradual decline in testosterone production with aging, known as andropause, is common and may have deleterious effects on men including decreased overall well-being, increased risk of cardiovascular disease and sarcopenia, reduced sexual function, and bone loss.

Occasionally, physicians may discourage male patients from getting testosterone replacement therapy based on a few recent studies indicating the therapy causes cardiovascular events, including myocardial infarctions. Yet, an extensive review of the testosterone replacement therapy literature reveals that the majority of clinical studies show that properly administered testosterone replacement therapy, in which estradiol and dihydrotestosterone levels are also controlled, has no adverse effects on myocardial infarction risk.

While testosterone is available in many forms, compounded troches offer several benefits:

  1. Convenience – easier than pellets or injections
  2. Decreased risk of cross contamination – men need not be concerned about others contacting the site of application, such as the arm or leg when a child or pet is held
  3. Rapid buccal or sublingual absorption means the dose can be a fraction of that required for topical forms of testosterone
  4. Patients can quickly achieve peak levels when desired

The testosterone controversy stems largely from poorly designed clinical studies in which patients were subjected to testosterone replacement therapy without having their estradiol and dihydrotestosterone levels properly controlled.

Int J Pharm Compd. 2015 May-Jun;19(3):195-203.
Click here to access the PubMed abstract of this article

Long-term Androgen Replacement Therapy: Effects on Aging Males with Late-Onset HypogonadismAndrogen replacement therapy was associated with significant decreases in waist circumstance and serum triglycerides; with significant increases in whole-body and leg muscle mass volumes, serum hemoglobin, IPSS voiding subscore, and a positive effect on erectile function. There was no significant difference between the groups in terms of severe adverse events.

Asian J Androl. 2016 Jan-Feb;18(1):25-34.
Effects of long-term androgen replacement therapy on the physical and mental statuses of aging males with late-onset hypogonadism: a multicenter randomized controlled trial in Japan (EARTH Study).
Click here to access the PubMed abstract of this article.

“The benefits of restoring serum testosterone in men with LOH were not significantly different between men older than 65 years of age and younger men. There were no indications that side effects were more severe in elderly men. The effects on prostate and urinary function and hematocrit were within safe margins. Age itself need not be a contraindication to testosterone treatment of elderly men with LOH.”

Korean J Urol. 2015 Apr;56(4):310-7.
Elderly men over 65 years of age with late-onset hypogonadism benefit as much from testosterone treatment as do younger men.
Click here to access the PubMed abstract of this article.

Testosterone Therapy and Cardiovascular Mortality

Testosterone therapy is recommended for men with symptomatic androgen deficiency and unequivocally low testosterone levels. Tanna et al. concluded from the study that testosterone therapy can be safely considered in men with appropriately diagnosed clinical androgen deficiency and increased cardiovascular risk after a thorough discussion of potential risks and with guideline-recommended safety monitoring.

Curr Atheroscler Rep. 2015 Mar;17(3):490.
The role of testosterone therapy in cardiovascular mortality: culprit or innocent bystander?
Click here to access the PubMed abstract of this article.

Testosterone Therapy in Men with Crohn’s Disease May Improve the Clinical Course

Crohn’s disease is an inflammatory chronic bowel disease characterized by an imbalanced production of pro-inflammatory mediators (tumor necrosis factor-α) and an increased recruitment of leukocytes to the site of inflammation. Low serum testosterone is associated with an increase in inflammatory factors, while testosterone administration reduces them. There is evidence for an immunomodulatory effect of testosterone on differentiation of regulatory T cells.

The study concluded that normalizing serum testosterone in men who have low testosterone levels had a positive effect on the clinical course of Crohn’s disease.

Horm Mol Biol Clin Investing. 2015 Jun;22(3):111-7.
Testosterone therapy in men with Crohn’s disease improves the clinical course of the disease: data from long-term observational registry study.
Click here to access the PubMed abstract of this article.

Plasma Testosterone and Risk of Ischemic Arterial Event in Elderly Men: The French 3C Cohort Study

Soisson et al. of the Center for Research in Epidemiology and Population Health, Hormones and Cardiovascular Disease Team, University of Paris-Sud (France), concluded that “Optimal range of plasma testosterone may confer cardiovascular protection and these results may have clinical implications in the management of testosterone deficiency.”

Maturitas. 2013 Jul;75(3):282-8.
A J-shaped association between plasma testosterone and risk of ischemic arterial event in elderly men: the French 3C cohort study.
Click here to access the PubMed abstract of this article

Testosterone: The Key to Male Vitality?

Kaplan and Hu of the Department of Urology, David Geffen School of Medicine at UCLA, note that “up to 25% of older men experience hypogonadism [low testosterone levels]. Prevalence is higher in men with comorbid disease and increases with age starting in the fourth decade. Hypogonadal men have lower muscle mass, bone mineral density, and hemoglobin, and are in poorer general health. During the past decade, there has been increasing awareness of the health benefits conferred by testosterone replacement therapy (TRT). TRT for hypogonadism increases muscle mass and bone mineral density, decreases fat mass, and improves mood, libido, and sexual performance. Despite these benefits, there is an historical fear that administration of exogenous testosterone may increase the risk of developing prostate cancer or an aggressive form of the disease.

Urology. 2013 Aug;82(2):321-6.
Use of Testosterone Replacement Therapy in the United States and Its Effect on Subsequent Prostate Cancer Outcomes.
Click here to access the PubMed abstract of this article

“Goodbye Androgen Hypothesis, Hello Saturation Model”

Observations in humans, animals, and PCa cell lines have led to the Saturation Model, ie, that “androgens have a finite, limited ability to stimulate prostate tissue, malignant or benign. This refinement is simple yet profound. Yes, prostate tissue requires androgens for optimal growth. However, it can only use a relatively small amount, beyond which additional androgen is merely excess. The saturation point is well below physiologic concentrations, which explains why manipulation of serum T into or out of the castrate range produces large changes in prostate biology, whereas normal prostate and PCa appear completely indifferent to variations in serum T from the near-physiologic to supraphysiologic range.”

Eur Urol. 2012 Nov;62(5):757-64
Serum testosterone and dihydrotestosterone and prostate cancer risk in the placebo arm of the Reduction by Dutasteride of Prostate Cancer Events trial.
Click here to access the PubMed abstract of this article.

Serum testosterone and dihydrotestosterone and prostate cancer risk

Muller et al. of Department of Surgery, Duke University School of Medicine found that “baseline serum testosterone and DHT levels were unrelated to PCa detection or grade. Our findings of the lowest testosterone levels being associated with the lowest PCa risk with no further changes with higher testosterone support a saturation model but must be confirmed in future studies…” After the exclusion criteria were applied, their study consisted of 149,354 men with prostate cancer.

Eur Urol. 2012 Nov;62(5):757-64.
Serum testosterone and dihydrotestosterone and prostate cancer risk in the placebo arm of the Reduction by Dutasteride of Prostate Cancer Events trial.
Click here to access the PubMed abstract of this article.

High estradiol levels can suppress testosterone production, and play a role in Metabolic Syndrome. Aromatase inhibitors such as anastrozole can reduce estradiol and increase serum bioavailable and total testosterone levels to the youthful normal range in older men with mild hypogonadism. Suppression of estradiol in men using low-dose anastrozole has been shown to have a positive effect on testosterone production without adverse effects during short term administration.

J Clin Endocrinol Metab. 2004 Mar;89(3):1174-80.
Effects of aromatase inhibition in elderly men with low or borderline-low serum testosterone levels.
Click here to access the PubMed abstract of this article.

In this case study anastrozole was used to restore fertility in a 29-year-old obese man who presented with a low sperm count in the setting of morbid obesity. Roth et al report “Treatment with an aromatase inhibitor, anastrozole, led to normalisation of the patient’s testosterone, luteinising hormone and follicle-stimulating hormone levels, suppression of serum estradiol levels, and to normalisation of spermatogenesis and fertility.”

Nat Clin Pract Endocrinol Metab. 2008 Jul;4(7):415-9.
Treatment of male infertility secondary to morbid obesity.
Click here to access the PubMed abstract of this article.

Testosterone Replacement Therapy for Men and Treatment of Depression

Testosterone replacement therapy (TRT) may be efficacious treatment for subthreshold depression in older men with hypogonadism.

Dysthymia is a chronic type of depression in which a person’s moods are regularly low. Testosterone replacement may be an effective antidepressant strategy for late-onset male dysthymia.

Ther Clin Risk Manag. 2009 Jun;5(3):427-48.
The benefits and risks of testosterone replacement therapy: a review.
Click here to access the PubMed abstract of this article.

J Clin Psychiatry. 2009 Jul;70(7):1009-16.
A randomized, double-blind, placebo-controlled study of testosterone treatment in hypogonadal older men with subthreshold depression (dysthymia or minor depression).
Click here to access the PubMed abstract of this article.

J Clin Psychopharmacol. 2009 Jun;29(3):216-21.
Effects of testosterone replacement in middle-aged men with dysthymia: a randomized, placebo-controlled clinical trial.
Click here to access the PubMed abstract of this article.

Arch Gen Psychiatry. 2008 Mar;65(3):283-9
Low free testosterone concentration as a potentially treatable cause of depressive symptoms in older men.
Click here to access the PubMed abstract of this article.

Low Testosterone Increases Mortality Risk in Men

A population-based cohort study followed 1954 men aged 20 to 89 years for an average of 7.2 years, and has demonstrated a link between low levels of testosterone and increased risk for mortality in adult men of all ages.

Administration of a transdermal testosterone (T) gel formulation to hypogonadal men provided dose-proportional increases in serum T levels to the normal adult male range. Testosterone 1% gel (50 or 100 mg/day) was compared to the permeation-enhanced T patch. After 180 days, skin irritation was reported in 5.5% of subjects treated with T gel and in 66% of subjects in the permeation-enhanced T patch group. This research at UCLA concluded that T gel replacement improved sexual function and mood, increased lean mass and muscle strength (principally in the legs), and decreased fat mass in hypogonadal men with less skin irritation and discontinuation compared with the recommended dose of the permeation-enhanced T patch.

J Clin Endocrinol Metab. 2000 Aug;85(8):2839-53
Transdermal testosterone gel improves sexual function, mood, muscle strength, and body composition parameters in hypogonadal men. Testosterone Gel Study Group.
Click here to access the PubMed abstract.

The following study concluded that replacing testosterone in hypogonadal men increases bone mineral density of the spine and hip, fat-free mass, prostate volume, erythropoiesis, energy, and sexual function. The full effect of testosterone on bone mineral density took 24 months, but the full effects on the other tissues took only 3-6 months.

J Clin Endocrinol Metab 2000 Aug;85(8):2670-7
Effects of testosterone replacement in hypogonadal men.
Click here to access the PubMed abstract

Am J Med 2001 May;110(7):563-72
Hypogonadism and androgen replacement therapy in elderly men.
Click here to access the PubMed abstract

Drugs Aging 1999 Aug;15(2):131-42
Risks versus benefits of testosterone therapy in elderly men.
Click here to access the PubMed abstract

The findings below suggest that low levels of testosterone and SHBG play some role in the development of insulin resistance and subsequent type 2 diabetes.

Diabetes Care 2000 Apr;23(4):490-4
Testosterone, sex hormone-binding globulin, and the development of type 2 diabetes in middle-aged men: prospective results from the Massachusetts male aging study.
Click here to access the PubMed abstract

Manifestations of testosterone deficiency have included depression, anxiety, irritability, insomnia, weakness, diminished libido, impotence, poor memory, reduced muscle and bone mass, and diminished sexual body hair. Although testosterone levels decline with age, there is great interindividual variability.

Am J Psychiatry 1998 Oct;155(10):1310-8
Age-associated testosterone decline in men: clinical issues for psychiatry.
Click here to access the PubMed abstract.

Massive obesity in males is associated with decreased total and free testosterone levels as well as elevated estradiol levels.

Med Hypotheses 1999 Jan;52(1):49-51
The hypogonadal-obesity cycle: role of aromatase in modulating the testosterone-estradiol shunt-a major factor in the genesis of morbid obesity.
Click here to access the PubMed abstract.

These results suggest that testosterone treatment might improve depressed mood in older men who have low levels of bioavailable testosterone.

J Clin Endocrinol Metab 1999 Feb;84(2):573-7
Bioavailable testosterone and depressed mood in older men: the Rancho Bernardo Study.
Click here to access the PubMed abstract

Oxytocin Therapy for Male Sexual Function

MacDonald and Feifel of the University of California, San Diego Medical Center Department of Psychiatry, published a case report on a male treated with a course of intranasal oxytocin treatment for social anxiety. The patient had significant, broad-spectrum improvements in sexual function, including libido, erection, and orgasm, and oxytocin was well tolerated.

J Sex Med. 2012 May;9(5):1407-10.
Dramatic improvement in sexual function induced by intranasal oxytocin.
Click here to access the PubMed abstract of this article.

The following results suggest that until the age of 60 years, the mean serum level of DHEAS is lower in patients with ED than in healthy volunteers.

Urology 2000 May;55(5):755-8
Serum dehydroepiandrosterone sulfate concentrations in men with erectile dysfunction.
Click here to access the PubMed abstract.

Sublingual sildenafil in the treatment of erectile dysfunction: faster onset of action with lower dose

Forty consecutive patients with erectile dysfunction (mean age was 55 years) for more than three months were included in this study. Sixty-five percent of patients (13/20) who received sublingual sildenafil achieved satisfying erections and coitus, whereas the rate was 15% in the placebo group (3/20). The mean onset of action with sublingual sildenafil was 15.5 minutes and lasted for an average of 40 minutes. Minimal headaches, sweating and flushing were noted as the side-effects. The conclusion: “20 mg sublingual sildenafil is safe and effective in the treatment of erectile dysfunction. Sublingual administration has some advantages as it is not effected by food ingestion and quickly appears in the circulation. These advantages provide a faster onset of action with a lower dose when compared to oral sildenafil. Sublingual use of sildenafil may be more cost-effective and possibly provides a more predictable onset of action.”

Int J Urol. 2004 Nov;11(11):989-92
Sublingual sildenafil in the treatment of erectile dysfunction: faster onset of action with less dose.
Click here to access the PubMed abstract of this article.

The International Journal of Pharmaceutical Compounding [March/April 2007;11(2):121] reported a formula for Sildenafil 20mg Troches (flavored) with a recommended beyond-use date of 180 days.